Pandemic

14

TUESDAY, 4:05 P.M.

As Jack cycled northward in the direction of Manhattan General Hospital, he was oblivious to the rush-hour traffic. Despite the frustrations he’d been experiencing to date with the subway death case, he now felt totally energized. Although he was well aware he needed proper identification only as an adjunct for potential epidemiological reasons if the causative agent turned out to be a virus capable of causing a pandemic, he now had a new and more personal stimulus for his interest in the case. His old nemesis, AmeriCare, and its sentinel hospital, MGH, were involved. And better still, the affair was beginning to feel as if it was not entirely kosher.

Like most doctors, Jack was cognizant of the seriousness associated with the distribution of organs for transplantation because of their shortage and the extent to which fairness was emphasized. Jack knew that at any given day about three thousand people in the USA alone were desperately waiting for hearts, with many patients dying before one can be found. He also knew that the distribution of the available hearts was carefully carried out by UNOS, the United Network for Organ Sharing. But from his conversation with Bonnie Vanderway, UNOS had not been involved with the patient he’d autopsied. Laughing at his own mixed metaphor, Jack thought he didn’t have to be a rocket scientist to smell something fishy.

Jack began to whistle as he pedaled. He had needed a diversion, and now he had found one that filled the bill in spades, and one that was going to continue even if it turned out a virus was not involved. At the same time, he cautioned himself for Laurie’s sake. The last time Jack had made a significant ruckus at Manhattan General Hospital over the results of a series of autopsies he’d done almost ten years ago, it had caused significant trouble for Laurie’s predecessor. The fallout had almost gotten Jack fired. And now, on this occasion, especially after Laurie’s specific warning, Jack knew he would have to be diplomatic, provided he was capable. Mainly, he would need to control his usual knee-jerk response of vociferously making it known to all parties involved when he confronted malfeasance or incompetence or a combination of both.

Reaching MGH, Jack found a street sign to lock up his Trek. He even locked up his helmet and bomber jacket with a separate wire lock that also secured the seat. He’d had a bad experience in the neighborhood and was intent on avoiding another.

For a moment he stood in the shadow of the soaring high-rise hospital. It had been a respected academic teaching hospital in its former life but had fallen on hard times in the early 1990s, when AmeriCare had been able to snap it up at a fire-sale price.

Inside, Jack took the elevators directly up to the fourth floor. He couldn’t help but remember the episode years ago when he had exposed a supervisor in the hospital’s laboratory who was purposefully spreading lethal infectious disease. The man had wanted to start an epidemic but luckily didn’t understand the dynamics. He had mistakenly chosen microorganisms that didn’t spread well person-to-person until he, too, had hit on the idea of influenza.

The moment Jack got off the elevator on the fourth floor, he was impressed. Although some portions of MGH had not been renovated after AmeriCare had taken over the facility, the Zhao Heart Center certainly had, and it had been done recently. It was the picture of modernity, and it appeared as if no expense had been spared. Jack imagined that patients couldn’t help but be dazzled and inspired with confidence. Although, knowing AmeriCare as well as he did, he hoped that glitz was backed up by an equal attention to the equipment behind the scenes.

As the clinic day was winding down, there were only a moderate number of patients in the waiting area and none at the main desk. Jack was able to walk directly up to one of the two receptionists. As befitting the environment, she was smartly dressed, and she gave Jack a warm smile and her full attention. Even that was new for Jack. In the past he’d felt that the AmeriCare management style was deficient in small details related to customer service.

Jack gave his name and asked for Bonnie Vanderway, just as she had instructed.

“Yes, of course,” the receptionist said. “We’ve been expecting you. I’ll let her know you’re here.”

Jack looked around a bit more at the decor. It was truly noteworthy, and perhaps the best hospital clinic environment he’d ever seen. Turning back to the receptionist, he asked when the clinic had been redone.

“Almost three years ago,” the receptionist said. “Do you like it, Doctor?”

“It would be hard not to like it,” Jack said. “I bet patients like it as well.”

“They love it,” the receptionist said.

“I suppose it’s named after a benefactor,” Jack commented.

“It is,” the receptionist agreed. “Mr. Wei Zhao.”

“Mr. Zhao must have been a very thankful patient.” Vaguely, he wondered how many millions it would take to have an entire heart center named after you in a private hospital.

“Mr. Zhao was not a patient,” the receptionist said. “I was told he was a Chinese billionaire businessman. He’s a member of our hospital board.”

“Lucky AmeriCare,” Jack said, and meant it.

“He is a very nice man,” the receptionist said. “I met him.”

At that moment Bonnie Vanderway appeared. She was a stocky woman with a broad face, and although younger than Jack had envisioned from her voice and her commanding manner of speaking, she exuded an air of assurance. Dressed in a long white coat over blue scrubs, she wore her moderate-length brunette hair neatly pulled back with a tortoiseshell barrette. After they had introduced themselves, Bonnie invited Jack back to her office. Despite the invitation, Jack felt she was mildly standoffish, which he didn’t know what to make of, although he worried it had something to do with her recently expressed legal reservations.

“Can I offer you some coffee?” Bonnie questioned, once they were seated.

“I’m fine,” Jack assured her.

“I managed to get ahold of Dr. Barton and he’ll be stopping by momentarily,” Bonnie said. “I also let the executive director know you had arrived. Her name is Katherine English, and she’ll be stopping by as well.”

“Excellent,” Jack said, although he would have preferred some time with Bonnie alone. In his experience bigwigs tended to be less forthcoming in marginal situations, giving credence to the adage: Too many cooks in the kitchen can spoil the stew. “Sounds like we’re going to have a regular party.”

“Excuse me?” Bonnie said. She’d heard Jack’s comment but didn’t know how to interpret it.

“I brought you a photo of the patient, so we can possibly confirm the identity,” Jack said, ignoring Bonnie’s rhetorical question. As he unfolded the photo and smoothed it out on Bonnie’s desktop, he silently scolded himself for already allowing a bit of his renowned sarcasm to emerge. He had to do better. For Laurie’s sake, he was intent on behaving himself.

“Oh, wow,” Bonnie said, looking at the photo. “That’s not very flattering.”

“Not likely to get her any modeling jobs,” Jack said. “Autopsy photos make everyone look remarkably terrible. It’s deliberate. They’re taken so that every possible blemish and abnormality stands out in stark relief.”

“Again, I wouldn’t be able to be sure this is the same person we operated on here,” Bonnie said. “Let me quickly show it to Tatiana. Do you mind if I leave you here for a moment? I think it would be helpful to be sure we are talking about the same person.”

“I’ll stay right here and mind my manners,” Jack assured her.

While Bonnie was gone, Jack looked around the office. There was a whiteboard with a calendar, which Jack guessed showed all the upcoming cases for the month. It appeared that they did about two transplants a week, most likely dependent on the availability of organs. Another whiteboard appeared to be scheduling for the entire clinical team except physicians. It was a complicated schedule involving three shifts a day, seven days a week. As clinical director, Bonnie was a busy lady.

“Tatiana is willing to confirm this is the patient that she handled,” Bonnie said, coming back into her office. “She would have come in person, but she’s with a patient and his family.” Bonnie tried to hand the photo back to Jack, but he waved it off, saying MGH could keep it for their files.

With a knock on the open office door to announce herself, a tall, aristocratic woman entered. Like Bonnie, she was wearing a long white coat, but underneath was a business suit instead of scrubs. Without any attempt at subterfuge, she gave Jack a once-over. Jack had stood when she arrived, and he stared back at her. Her straightforwardness reminded him of his grammar school principal back in South Bend, Indiana. It wasn’t a wholly comfortable remembrance. Jack had been what the principal had described as a willful child, and she’d let him know on multiple occasions.

Bonnie formally introduced Jack to Katherine English, the executive director of the Heart Transplant Program.

“Bonnie filled me in on your earlier phone conversation,” Kathrine said, dispensing with any small talk.

“There’s been an update,” Bonnie told her. “Dr. Stapleton brought in an autopsy photo, and Tatiana has confirmed it is a patient we operated on.”

“I see,” Katherine said. “That is obviously disappointing news for us. We like to think that our patients all have long and healthy lives, thanks to our efforts.”

“At this early stage, it’s my impression that this woman’s death was not immediately associated with her surgery,” Jack said. “Actually, there was every indication your team did a great job. Grossly and microscopically, the heart appeared absolutely perfect, without a trace of inflammation.”

“How did the patient die?” Katherine asked.

“Manner or cause?” Jack asked.

“Both, I guess,” Katherine said.

“The manner was natural,” Jack said. “The cause we don’t know yet. The mechanism, I believe, was an overwhelming respiratory problem called cytokine storm, possibly of an infectious origin, which is why we are desperate for an ID. If it proves to be infectious, which we are attempting to do, we need to know her social contacts to either quarantine or monitor them.”

“That makes total sense,” Katherine said.

Another knock on the open office door heralded the arrival of another tall, aristocratic individual, making Jack wonder if AmeriCare was cloning these people. Jack struggled to rein in his instinctual cynicism. This new visitor was a particularly handsome male, about Jack’s height, six-two, and about Jack’s age. And like Jack, he appeared to be in excellent physical shape. Similar to Bonnie, he was dressed in a long white coat over scrubs. Unlike Bonnie, he had a stethoscope casually slung across his shoulders. A bit of ECG tape protruded from one of his pockets. A surgical mask dangled down over his chest.

“Hello, Dr. Barton,” Bonnie said with obvious respect. She then formally introduced Jack to Dr. Chris Barton, cardiac surgeon.

“I understand you’ve brought me some bad news,” Chris said to Jack. His tone was pleasant and his demeanor mild.

“I suppose you could say that,” Jack said, struggling to behave himself. He was privy to what he called the “narcissistic cardiac surgeon personality,” which saw everything from a personal vantage point.

“It has been confirmed it is one of your patients,” Bonnie said.

“That’s terrible,” Chris said. “It’s a tragedy, as the case went so smoothly, including the immediate post-op portion. I hate to see it mess up my stats.”

Jack bit his tongue to keep from making an appropriate comment about the difference between someone’s life and someone’s stats. Instead, he said, “I thought you might be interested to hear that the heart looked fantastic. It was situated perfectly, and all the anastomoses were completely healed and fully patent. But I do have a question: I have been told it was a targeted donation. How common is that?”

“It’s not common with the heart,” Chris said. “Kidney and liver, yes, but heart, no. Yet it does happen.”

“How was it that it happened in this case?” Jack asked. He decided to go for broke.

“To tell you the truth, I don’t know the details,” Chris said. “The patient and the heart came in together. I was just the plumber and hooked the thing up. It was a perfect donor heart and a good match, or so we were told. All the preparation in terms of matching and physiological testing was done at a sister institution.”

“Any idea of where the heart came from?” Jack asked.

“I was told by the surgeon who came in with the heart, who happens to be a friend, that a motorcyclist with severe head trauma had arrived in the hospital’s emergency room the same day the patient presented in cardiac extremis. Obviously, serendipity played a major role, because apart from the coincidental timing, both patients had the rare blood type of AB-negative.”

“That is serendipitous,” Jack agreed. “So this targeted donation occurred outside of UNOS.”

“Of course,” Chris said. “That’s what a targeted donation is. It’s from one person to another person. I don’t know for sure, but I would imagine the families knew each other, or if they didn’t, they do now. It was a gracious thing for the grieving family to do. A life was lost, but a life was saved. Well, at least for a few months.”

“How does UNOS feel about such an arrangement?” Jack asked. Despite what he was hearing, his intuition was still ringing alarm bells. He couldn’t help but feel there was something decidedly improper about this story. It was too coincidental, too pat. Besides, AmeriCare was somehow complicit.

“In this particular situation, UNOS had no jurisdiction,” Chris explained. “But in all fairness, I was also told that the patient had been on UNOS’s waiting list for a heart for over a year. AB-negative hearts are rarer than hen’s teeth.” He chuckled at his own joke.

“What about the other HLA antigens that should match between a donor organ and the recipient?” Jack questioned. “Were they a good match in this case?”

“Very good,” Chris said. “I was told all twelve human leukocyte antigens matched, which is rare. I suppose that is why the patient did so well post-op. She was air-lifted out of here the day she got out of the cardiac surgery recovery room to continue her recovery at our sister institution. I couldn’t have been more pleased with her course. I felt like a million bucks.”

I’m sure you did, Jack thought but didn’t say. Instead, he said, “Our Toxicology Department determined on a screen that the patient had no immunosuppressants on board. Does that surprise you?”

“It more than surprises me,” Chris said. “In medicine, when you get an unexpected lab result, you do it again. I’d advise you to have your toxicologists do it a second time. The patient had to have immunosuppressants in her system. I know for certain, because we started them in surgery, kept them up while she was in the cardiac surgery recovery room, and sent them with her as part of her discharge packet.”

Although Jack had more questions for the surgeon, another knock on the open office door caught his attention. Turning in its direction by reflex, he was in for a big shock. In walked the embodiment of everything Jack hated about AmeriCare, Charles Kelley, the hospital CEO and president. When Jack had entered medicine the previous century, the heads of hospitals were called administrators and were often doctors who had been willing to take MBA courses. The benefit was that the hospital continued to be oriented around their original, basic altruistic function of taking care of the sick. Now, at MGH, the chief was not a doctor but rather a trained businessman. It had been a necessary transition, because the main goal had changed from patient care to providing a handsome return on investment for faceless investors.

Charles Kelley was a striking figure. At six-eight, he towered over most everyone. Sandy-haired, continually tanned, impeccably dressed in silk suits, and commanding a multimillion-dollar salary, he seemed to have come directly from central casting. “Well, well,” he said in a condescendingly acerbic tone, “if it isn’t our favorite medical examiner.”

Biting back equivalent sarcasm, Jack struggled to control himself. Previously, when he had first investigated and eventually outed the MGH microbiology terrorist who had been trying to start the epidemic for his advertising executive sister’s benefit, Jack had had multiple run-ins with Charles. Charles had seen Jack as trouble from the word go and made significant attempts to have him fired. As Charles was politically connected, with close personal and professional ties to the mayor, he nearly succeeded. And now, since he was just as close with the new mayor and for the same reason — namely, significant campaign contributions — Jack knew he was on very thin ice. It was Laurie who would be in the crosshairs now.

“I’ve heard you’re here to bring us bad news,” Charles continued.

“As a city employee I’m always striving to be of service,” Jack said, and then inwardly lambasted himself for being unnecessarily provocative with such obvious sarcasm.

“I’ve got to do afternoon rounds,” Chris said, interrupting the exchange between Jack and Charles. “So I’ll be running along. Thanks for the info.” He touched his forehead in a kind of half-assed salute. Jack watched him go with regret. He would have liked to ask more questions.

As Chris departed, Katherine spoke up: “It has been confirmed with a photograph that Dr. Stapleton brought that the person he autopsied is the individual we operated on for the Dover Valley Hospital.”

“That’s unfortunate,” Charles commented. He stared daggers at Jack. “You certainly are a conveyer of distressing news. Tell me, do you rub everyone you meet the wrong way?”

“Just those people I don’t respect,” Jack said, and inwardly groaned at his lack of self-control. He was hopeless.

“I’ll pretend I didn’t hear that,” Charles said. “Let’s cut to the chase. I understand that you’re looking to identify this unfortunate individual.”

“It could be critical if it is determined she died of a potentially contagious disease,” Jack said, hoping to move away from ad hominem retorts.

“I have spoken with our counsel. We cannot give you any medical details of our service without a proper subpoena. What I am willing to give you is her name.”

“That’s a start,” Jack said. “I don’t think details of her recent surgery will be critical. The name and permanent address and anything else you have will suffice for now.”

“We don’t have the permanent address,” Charles admitted.

“Then the billing information will be adequate,” Jack said.

“We don’t have any billing information,” Charles said. “The entire admission, including the surgery, was completely covered by our sister hospital, Dover Valley Hospital, whose heart center is associated with our heart center. It was their show. We were just being supportive to save a life.”

“They paid you directly?” Jack said with amazement. This case certainly was unique on all fronts. One hospital paying another, even if they were associated, raised further red flags in his mind. Knowing AmeriCare’s penchant for maximizing return on investment, he couldn’t help but wonder what kind of money was involved. His intuition was telling him millions, and Jack knew money talked.

“The Dover Valley Hospital was within weeks of getting their heart transplant certification,” Charles explained. “If they could have waited, they would have. My understanding is that they had the insurance coverage all arranged, just like they had everything else arranged. It was the patient’s condition that dictated a change in venue. All we had to do was have the patient sign our operative consent form and do the procedure.”

“And the patient’s name?” Jack asked.

“Carol Weston Stewart,” Charles said. He handed Jack one of his business cards with the name hand-printed on the back. “I believe this satisfies the reason for your visit here to MGH. And now I would like you to leave. You helped us in the past, I’ll give you that. But in the process, you were like the proverbial bull in the china shop, and I will sleep better tonight knowing you were escorted off the premises.”

Charles turned and waved for several uniformed security men who had accompanied him to the heart center to come into Bonnie’s office. As soon as they did, he directed them to escort Jack out onto the street.

“You mustn’t make a fuss on my behalf,” Jack said, trying to suppress a smile.

“Oh, but we insist,” Charles said.

Jack made it a point to shake hands with Bonnie Vanderway, whom he credited for his progress of getting the sought-after name. Then he merely provocatively smiled and waved at Charles before he followed the security people out into the hall.

“Such a nice man,” Jack said, as the group waited for the elevator.

Outside, as he unlocked his bike, Jack smiled anew. Not only had he managed to get the name of Carol Weston Stewart, but he had the satisfaction of possibly ruining Charles Kelley’s day. But more important, he felt even more motivated about his diversion. The fact that Charles Kelley himself had felt compelled to become involved spoke volumes. It was like a neon sign proclaiming something weird was afoot.